Provider Demographics
NPI:1538245832
Name:LICUDINE & LICUDINE MD SC
Entity type:Organization
Organization Name:LICUDINE & LICUDINE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LICUDINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-379-4348
Mailing Address - Street 1:7049 N KILPATRICK AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2128
Mailing Address - Country:US
Mailing Address - Phone:847-677-7264
Mailing Address - Fax:
Practice Address - Street 1:4758 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3619
Practice Address - Country:US
Practice Address - Phone:773-379-4348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-29
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046217208600000X
IL036051696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046217Medicaid
IL036051696Medicaid
IL036051696Medicaid
IL036046217Medicaid
IL472970Medicare ID - Type Unspecified
IL487530Medicare ID - Type Unspecified